Contact Lens-Related Eye Infection Report Form
Use this form to report a contact lens-related eye infection and share the key details needed for follow-up.
Reporter and Patient Details
Reporter full name
*
First Name
Middle Name
Last Name
Relationship to affected person
*
Please Select
Self
Parent/Guardian
Family member
Healthcare professional
Friend
Other
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Affected person's age
Affected person's date of birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infection and Contact Lens Details
Affected eye(s)
*
Left
Right
Both
Main symptoms experienced
*
Redness
Pain
Discharge
Light sensitivity
Blurred vision
Swelling
Itching
Tearing
Other
When symptoms first started
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Wore contact lenses in the 24 hours before symptoms began?
*
Yes
No
Not sure
Lens type used
*
Please Select
Daily disposable
Bi-weekly
Monthly
Toric
Multifocal
Rigid gas permeable
Other
Lens cleaning, storage, or exposure details
Care and Follow-Up Information
Have you contacted an eye care provider or sought care?
*
Yes
No
Clinic or provider name
Treatment already received
Additional notes
Submit Report
Should be Empty: